Abstract
Non-invasive imaging of coronary arteries by transthoracic echocardiography is an emerging diagnostic tool to study the left main (LM), left descending artery (LAD), circumflex (Cx) and right coronary artery (RCA). Impaired coronary circulation can be assessed by measuring coronary velocity flow reserve (CVFR) by transthoracic Doppler echocardiography. Coronary artery stenoses can be identified as localized colour aliasing and accelerated flow velocities. We report a case with an acute coronary syndrome (ACS) of a 46-year-old man. With non-invasive imaging of coronary arteries by transthoracic echocardiography (TTE), we identified a segment of the mid right coronary artery (RCA) suggestive of stenosis with localized colour aliasing and accelerated flow velocity. We found a high ratio between the stenotic peak velocity and the prestenotic peak velocity, and a pathologic coronary flow velocity reserve (CFVR) distal to the stenosis in the posterior interventricular descending branch (RDP). Subsequent coronary angiography demonstrated one vessel disease with a stenosis in segment 3 of RCA, which was successfully treated with percutaneos coronary intervention PCI. Two weeks following the PCI procedure he was readmitted to hospital with chest pain. A subacute stent thrombosis was questioned, and repeated echocardiography was preformed. The mid portion of RCA showed normal and laminar flow. The CVFR of RCA measured in the RDP showed normal vasodilatory response, confirming an open RCA without any flow limitation. A repeated coronary angiogram demonstrated only a mild in stent intimal hyperplasia. This case illustrates the value of transthoracic echocardiography as a tool both in the diagnosis and the follow-up of chest pain disorders and coronary flow problems. Transthoracic echocardiography allows both direct visualization of the various coronary segments and assessment of the CVFR.
Highlights
Non-invasive imaging of coronary arteries by transthoracic echocardiography is an emerging diagnostic tool to study the left main (LM), left descending artery (LAD), circumflex (Cx) and right coronary artery (RCA) [1]
Impaired coronary circulation can be assessed by measuring coronary velocity flow reserve (CVFR) by transthoracic Doppler echocardiography [2,3,4]
We report a case with an acute coronary syndrome (ACS), where transthoracic echocardiography showed a significant stenosis of the middle part of the RCA, confirmed by pathologic CVFR measured in the posterior interventricular descending branch (RDP) and by coronary angiography
Summary
Non-invasive imaging of coronary arteries by transthoracic echocardiography is an emerging diagnostic tool to study the left main (LM), left descending artery (LAD), circumflex (Cx) and right coronary artery (RCA) [1]. The LM, LAD, proximal and mid segments of the Cx, RDP and proximal segment of RCA showed laminar flow and normal flow velocities, without any signs of colour-aliasing suggestive of stenosis. In the subcostal 4-chamber view we identified a segment of the mid RCA with colouraliasing (Figure 1), and the diastolic peak velocity measured with pulsed wave Doppler was 1.39 m/s (Figure 1). These findings were confirmed with the use of a modified subcostal short axis view. The flow acceleration was quantified as the ratio of peak diastolic flow velocity at the site of aliasing to nearest upstream non-accelerated prestenotic peak diastolic flow velocity This ratio was 3.75 (Table 1), compatible with a significant stenosis in the mid RCA. A repeated coronary angiogram was performed three months later demonstrating only mild in stent intimal hyperplasia
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